Community acquired pneumonia (CAP) is a major cause of morbidity and mortality. Although administration of antibiotic therapy within four hours of presentation for patients hospitalized with pneumonia has been associated with a significant reduction in morbidity and mortality, VA performance for this performance measure currently lags behind the non-VA healthcare system and falls below established CMS/JCAHO and VA targets.
This project was intended to rapidly translate what is known about timely administration of initial antibiotic therapy for CAP into information useful for facility-level quality improvement.
Key informants from 20 VA Medical Centers across the nation were invited to participate in a web-based survey and in focus groups. Sites were selected to represent higher- and lower-performers with regard to timely administration and appropriate selection of antibiotics for patients with CAP. Each site’s Chief of Staff identified seven key informants, including an emergency room medical provider, emergency room nurse, inpatient ward attending or hospitalist, general medical floor nurse, radiologist, pharmacist, and quality manager. A total of 139 key informants were identified, contacted, and asked to complete a 15-20 minute web-based survey to address the following questions: 1) points of delay in patient care from the time of presentation to antibiotic administration, 2) specific barriers contributing to these delays, 3) interventions employed to improve performance on these quality measures, and 4) the role of facility stakeholders in performance improvement efforts. In addition, key informants were invited to and participate in a 1½ hour focus group to address these questions using qualitative research methods.
Overall, 79.9% of the 139 key informants completed the web-based survey (75.4% of the high performing site responders and 84.3% of the low performing site responders). Forty percent of the key informants attended a focus group, with equal numbers from higher- and lower-performing sites. Survey respondents identified performance and interpretation of the chest radiograph and ordering and delivering antibiotics as the most influential steps in patient care that result in successful performance on this measure. Barriers causing these delays included transportation delays (of patient or radiograph equipment), communication delays between providers, lack of a ‘stat’ reading for radiographs or pharmacy priority alert for antibiotics, and delay in receiving antibiotics in the ED. Strategies discussed to improve performance on this quality measure included: 1) provider reminders, either written or electronic, 2) provider audit and feedback, 3) medical provider education, and 4) formal processes for continuous quality improvement. The focus group discussions identified a top-down leadership approach, beginning with the Hospital Director and the Chief of Staff, as crucial to the success of such quality improvement efforts. As with other quality improvement programs, multi-pronged approaches that target a number of systems and stakeholders were deemed likely to be most successful. A self-assessment checklist and set of quality improvement solutions were developed to assist key stakeholders identify the barriers to timely antibiotic administration at their facility.
The information from this project is designed to provide VA stakeholders (e.g., policy makers, quality managers, clinicians) the information and tools necessary to increase the proportion of patients hospitalized with pneumonia who receive appropriate antibiotics within 4 hours.
- Fine MJ. Ensuring timely administration of antibiotic therapy for patients with community-acquired pneumonia in the VA Healthcare System [plenary talk]. Paper presented at: VA Optimizing Clinical Performance Through Systems Management Conference; 2006 Jun 6; Phoenix, AZ.
- Aspinall SL, Hyman KB, Fine MJ. Ensuring timely administration of antibiotic therapy for patients with community-acquired pneumonia. Paper presented at: VA VISN Formulary Leaders Meeting; 2006 May 17; Chicago, IL.